Method and apparatus for re-attaching the labrum to the acetabulum, including the provision and use of a novel suture anchor system

ABSTRACT

Apparatus for securing a first object to a second object, the apparatus comprising: an elongated body having a distal end, a proximal end, and a lumen extending between the distal end and the proximal end, the lumen comprising a first section and a second section, the first section of the lumen being disposed distal to the second section of the lumen, and with the first section of the lumen having a wider diameter than the second section of the lumen; at least one longitudinally-extending slit extending through the side wall of the elongated body and communicating with the lumen, the at least one longitudinally-extending slit having a distal end and a proximal end, with the distal end of the at least one longitudinally-extending slit being spaced from the distal end of the elongated body; and an elongated element extending through the lumen of the elongated body.

REFERENCE TO PENDING PRIOR PATENT APPLICATIONS

This patent application is a continuation of pending prior U.S. patentapplication Ser. No. 13/642,168, filed Dec. 26, 2012 by Chris Pamichevet al. for METHOD AND APPARATUS FOR RE-ATTACHING THE LABRUM TO THEACETABULUM, INCLUDING THE PROVISION AND USE OF A NOVEL SUTURE ANCHORSYSTEM, which in turn is a 371 national stage entry of International(PCT) Patent Application No. PCT/US11/21173, filed Jan. 13, 2011 byPivot Medical, Inc. for METHOD AND APPARATUS FOR RE-ATTACHING THE LABRUMTO THE ACETABULUM, INCLUDING THE PROVISION AND USE OF A NOVEL SUTUREANCHOR SYSTEM, which in turn:

(i) is a continuation-in-part of prior U.S. patent application Ser. No.12/839,246, filed Jul. 19, 2010 by Chris Pamichev et al. for METHOD ANDAPPARATUS FOR RE-ATTACHING THE LABRUM TO THE ACETABULUM, INCLUDING THEPROVISION AND USE OF A NOVEL SUTURE ANCHOR SYSTEM, which in turn claimsbenefit of (1) prior U.S. Provisional Patent Application Ser. No.61/271,205, filed Jul. 17, 2009 by Chris Pamichev et al. for METHOD ANDAPPARATUS FOR RE-SECURING THE LABRUM TO THE ACETABULUM, INCLUDING THEPROVISION AND USE OF A NOVEL NANO TACK SYSTEM, and (2) prior U.S.Provisional Patent Application Ser. No. 61/326,709, filed Apr. 22, 2010by Chris Pamichev et al. for METHOD AND APPARATUS FOR RE-SECURING THELABRUM TO THE ACETABULUM, INCLUDING THE PROVISION AND USE OF A NOVELSUTURE ANCHOR SYSTEM; and

(ii) claims benefit of prior U.S. Provisional Patent Application Ser.No. 61/326,709, filed Apr. 22, 2010 by Chris Pamichev et al. for METHODAND APPARATUS FOR RE-SECURING THE LABRUM TO THE ACETABULUM, INCLUDINGTHE PROVISION AND USE OF A NOVEL SUTURE ANCHOR SYSTEM.

The above-identified patent applications are hereby incorporated hereinby reference.

FIELD OF THE INVENTION

This invention relates to surgical methods and apparatus in general, andmore particularly to surgical methods and apparatus for treating a hipjoint.

BACKGROUND OF THE INVENTION The Hip Joint in General

The hip joint is a ball-and-socket joint which movably connects the legto the torso. The hip joint is capable of a wide range of differentmotions, e.g., flexion and extension, abduction and adduction, medialand lateral rotation, etc. See FIGS. 1A, 1B, 1C and 1D.

With the possible exception of the shoulder joint, the hip joint isperhaps the most mobile joint in the body. Significantly, and unlike theshoulder joint, the hip joint carries substantial weight loads duringmost of the day, in both static (e.g., standing and sitting) and dynamic(e.g., walking and running) conditions.

The hip joint is susceptible to a number of different pathologies. Thesepathologies can have both congenital and injury-related origins. In somecases, the pathology can be substantial at the outset. In other cases,the pathology may be minor at the outset but, if left untreated, mayworsen over time. More particularly, in many cases, an existingpathology may be exacerbated by the dynamic nature of the hip joint andthe substantial weight loads imposed on the hip joint.

The pathology may, either initially or thereafter, significantlyinterfere with patient comfort and lifestyle. In some cases, thepathology can be so severe as to require partial or total hipreplacement. A number of procedures have been developed for treating hippathologies short of partial or total hip replacement, but theseprocedures are generally limited in scope due to the significantdifficulties associated with treating the hip joint.

A better understanding of various hip joint pathologies, and also thecurrent limitations associated with their treatment, can be gained froma more thorough understanding of the anatomy of the hip joint.

Anatomy of the Hip Joint

The hip joint is formed at the junction of the leg and the torso. Moreparticularly, and looking now at FIG. 2, the head of the femur isreceived in the acetabular cup of the hip, with a plurality of ligamentsand other soft tissue serving to hold the bones in articulatingcondition.

More particularly, and looking now at FIG. 3, the femur is generallycharacterized by an elongated body terminating, at its top end, in anangled neck which supports a hemispherical head (also sometimes referredto as “the ball”). As seen in FIGS. 3 and 4, a large projection known asthe greater trochanter protrudes laterally and posteriorly from theelongated body adjacent to the neck of the femur. A second, somewhatsmaller projection known as the lesser trochanter protrudes medially andposteriorly from the elongated body adjacent to the neck. Anintertrochanteric crest (FIGS. 3 and 4) extends along the periphery ofthe femur, between the greater trochanter and the lesser trochanter.

Looking next at FIG. 5, the hip socket is made up of three constituentbones: the ilium, the ischium and the pubis. These three bones cooperatewith one another (they typically ossify into a single “hip bone”structure by the age of 25 or so) in order to collectively form theacetabular cup. The acetabular cup receives the head of the femur.

Both the head of the femur and the acetabular cup are covered with alayer of articular cartilage which protects the underlying bone andfacilitates motion. See FIG. 6.

Various ligaments and soft tissue serve to hold the ball of the femur inplace within the acetabular cup. More particularly, and looking now atFIGS. 7 and 8, the ligamentum teres extends between the ball of thefemur and the base of the acetabular cup. As seen in FIGS. 8 and 9, alabrum is disposed about the perimeter of the acetabular cup. The labrumserves to increase the depth of the acetabular cup and effectivelyestablishes a suction seal between the ball of the femur and the rim ofthe acetabular cup, thereby helping to hold the head of the femur in theacetabular cup. In addition to the foregoing, and looking now at FIG.10, a fibrous capsule extends between the neck of the femur and the rimof the acetabular cup, effectively sealing off the ball-and-socketmembers of the hip joint from the remainder of the body. The foregoingstructures (i.e., the ligamentum teres, the labrum and the fibrouscapsule) are encompassed and reinforced by a set of three main ligaments(i.e., the iliofemoral ligament, the ischiofemoral ligament and thepubofemoral ligament) which extend between the femur and the perimeterof the hip socket. See, for example, FIGS. 11 and 12, which show theiliofemoral ligament, with FIG. 11 being an anterior view and FIG. 12being a posterior view.

Pathologies of the Hip Joint

As noted above, the hip joint is susceptible to a number of differentpathologies. These pathologies can have both congenital andinjury-related origins.

By way of example but not limitation, one important type of congenitalpathology of the hip joint involves impingement between the neck of thefemur and the rim of the acetabular cup. In some cases, and looking nowat FIG. 13, this impingement can occur due to irregularities in thegeometry of the femur. This type of impingement is sometimes referred toas cam-type femoroacetabular impingement (i.e., cam-type FAI). In othercases, and looking now at FIG. 14, the impingement can occur due toirregularities in the geometry of the acetabular cup. This latter typeof impingement is sometimes referred to as pincer-type femoroacetabularimpingement (i.e., pincer-type FAI). Impingement can result in a reducedrange of motion, substantial pain and, in some cases, significantdeterioration of the hip joint.

By way of further example but not limitation, another important type ofcongenital pathology of the hip joint involves defects in the articularsurface of the ball and/or the articular surface of the acetabular cup.Defects of this type sometimes start out fairly small but often increasein size over time, generally due to the dynamic nature of the hip jointand also due to the weight-bearing nature of the hip joint. Articulardefects can result in substantial pain, induce and/or exacerbatearthritic conditions and, in some cases, cause significant deteriorationof the hip joint.

By way of further example but not limitation, one important type ofinjury-related pathology of the hip joint involves trauma to the labrum.More particularly, in many cases, an accident or sports-related injurycan result in the labrum being torn away from the rim of the acetabularcup, typically with a tear running through the body of the labrum. SeeFIG. 15. These types of injuries can be very painful for the patientand, if left untreated, can lead to substantial deterioration of the hipjoint.

The General Trend Toward Treating Joint Pathologies UsingMinimally-Invasive, and Earlier, Interventions

The current trend in orthopedic surgery is to treat joint pathologiesusing minimally-invasive techniques. Such minimally-invasive, “keyhole”surgeries generally offer numerous advantages over traditional, “open”surgeries, including reduced trauma to tissue, less pain for thepatient, faster recuperation times, etc.

By way of example but not limitation, it is common to re-attachligaments in the shoulder joint using minimally-invasive, “keyhole”techniques which do not require large incisions into the interior of theshoulder joint. By way of further example but not limitation, it iscommon to repair torn meniscal cartilage in the knee joint, and/or toreplace ruptured ACL ligaments in the knee joint, usingminimally-invasive techniques.

While such minimally-invasive approaches can require additional trainingon the part of the surgeon, such procedures generally offer substantialadvantages for the patient and have now become the standard of care formany shoulder joint and knee joint pathologies.

In addition to the foregoing, in view of the inherent advantages andwidespread availability of minimally-invasive approaches for treatingpathologies of the shoulder joint and knee joint, the current trend isto provide such treatment much earlier in the lifecycle of thepathology, so as to address patient pain as soon as possible and so asto minimize any exacerbation of the pathology itself. This is in markedcontrast to traditional surgical practices, which have generallydictated postponing surgical procedures as long as possible so as tospare the patient from the substantial trauma generally associated withinvasive surgery.

Treatment for Pathologies of the Hip Joint

Unfortunately, minimally-invasive treatments for pathologies of the hipjoint have lagged far behind minimally-invasive treatments forpathologies of the shoulder joint and the knee joint. This is generallydue to (i) the constrained geometry of the hip joint itself, and (ii)the nature and location of the pathologies which must typically beaddressed in the hip joint.

More particularly, the hip joint is generally considered to be a “tight”joint, in the sense that there is relatively little room to maneuverwithin the confines of the joint itself. This is in marked contrast tothe shoulder joint and the knee joint, which are generally considered tobe relatively “spacious” joints (at least when compared to the hipjoint). As a result, it is relatively difficult for surgeons to performminimally-invasive procedures on the hip joint.

Furthermore, the pathways for entering the interior of the hip joint(i.e., the natural pathways which exist between adjacent bones and/ordelicate neurovascular structures) are generally much more constrainingfor the hip joint than for the shoulder joint or the knee joint. Thislimited access further complicates effectively performingminimally-invasive procedures on the hip joint.

In addition to the foregoing, the nature and location of the pathologiesof the hip joint also complicate performing minimally-invasiveprocedures on the hip joint. By way of example but not limitation,consider a typical detachment of the labrum in the hip joint. In thissituation, instruments must generally be introduced into the joint spaceusing an angle of approach which is offset from the angle at which theinstrument addresses the tissue. This makes drilling into bone, forexample, significantly more complicated than where the angle of approachis effectively aligned with the angle at which the instrument addressesthe tissue, such as is frequently the case in the shoulder joint.Furthermore, the working space within the hip joint is typicallyextremely limited, further complicating repairs where the angle ofapproach is not aligned with the angle at which the instrument addressesthe tissue.

As a result of the foregoing, minimally-invasive hip joint proceduresare still relatively difficult to perform and relatively uncommon inpractice. Consequently, patients are typically forced to manage theirhip pain for as long as possible, until a resurfacing procedure or apartial or total hip replacement procedure can no longer be avoided.These procedures are generally then performed as a highly-invasive, openprocedure, with all of the disadvantages associated withhighly-invasive, open procedures.

As a result, there is, in general, a pressing need for improved methodsand apparatus for treating pathologies of the hip joint.

Re-Attaching the Labrum of the Hip Joint

As noted above, hip arthroscopy is becoming increasingly more common inthe diagnosis and treatment of various hip pathologies. However, due tothe anatomy of the hip joint and the pathologies associated with thesame, hip arthroscopy is currently practical for only selectedpathologies and, even then, hip arthroscopy has generally met withlimited success.

One procedure which is sometimes attempted arthroscopically relates tothe repair of a torn and/or detached labrum. This procedure may beattempted (i) when the labrum has been damaged but is still sufficientlyhealthy and intact as to be capable of repair and/or re-attachment, and(ii) when the labrum has been deliberately detached (e.g., so as toallow for acetabular rim trimming to treat a pathology such as apincer-type FAI) and needs to be subsequently re-attached. See, forexample, FIG. 16, which shows a normal labrum which has its basesecurely attached to the acetabulum, and FIG. 17, which shows a portionof the labrum (in this case the tip) detached from the acetabulum. Inthis respect it should also be appreciated that repairing the labrumrather than removing the labrum is generally desirable, inasmuch asstudies have shown that patients whose labrum has been repaired tend tohave better long-term outcomes than patients whose labrum has beenremoved.

Unfortunately, current methods and apparatus for arthroscopicallyrepairing (e.g., re-attaching) the labrum are somewhat problematic. Thepresent invention is intended to improve upon the current approaches forlabrum repair.

More particularly, current approaches for arthroscopically repairing thelabrum typically use apparatus originally designed for use inre-attaching ligaments to bone. For example, one such approach utilizesa screw-type bone anchor, with two sutures extending therefrom, andinvolves deploying the bone anchor in the acetabulum above the labrumre-attachment site. A first one of the sutures is passed either throughthe detached labrum or, alternatively, around the detached labrum. Thenthe first suture is tied to the second suture so as to support thelabrum against the acetabular rim. See FIG. 18.

Unfortunately, bone anchors of the sort described above aretraditionally used for re-attaching ligaments to bone and, as a result,tend to be relatively large, since they must carry the substantialpull-out forces normally associated with ligament reconstruction.However, this large anchor size is generally unnecessary for labrumre-attachment, since the labrum is not subjected to substantial pull-outforces, and the large anchor size typically causes unnecessary trauma tothe patient.

Furthermore, the large size of traditional bone anchors can beproblematic when the anchors are used for labrum re-attachment, sincethe bone anchors generally require a substantial bone mass for secureanchoring, and such a large bone mass is generally available only asubstantial distance up the acetabular shelf. In addition, the largesize of the bone anchors generally makes it necessary to set the boneanchor a substantial distance up the acetabular shelf, in order toensure that the distal tip of the bone anchor does not inadvertentlybreak through the acetabular shelf and contact the articulating surfacesof the joint. However, labral re-attachment utilizing a bone anchor sethigh up into the acetabular shelf creates a suture path, and hence alabral draw force, which is not directly aligned with the portion of theacetabular rim where the labrum is to be re-attached. As a result, an“indirect” draw force (also known as eversion) is typically applied tothe labrum, i.e., the labrum is drawn around the rim of the acetabulumrather than directly into the acetabulum. See FIG. 18. This cansometimes result in a problematic labral re-attachment and, ultimately,can lead to a loss of the suction seal between the labrum and femoralhead, which is a desired outcome of the labral re-attachment procedure.

Alternatively, the suture path can also surround the labrum, thusplacing a suture on both sides of the labrum, including the articularside of the labrum, and thus exposing the articular surface of the femurto a foreign body, which could in turn cause damage to the articularsurface (i.e., the articular cartilage) of the femur.

Accordingly, a new approach is needed for arthroscopically re-attachingthe labrum to the acetabulum.

SUMMARY OF THE INVENTION

The present invention provides a novel method and apparatus forre-attaching the labrum to the acetabulum. Among other things, thepresent invention comprises the provision and use of a novel sutureanchor system.

In one form of the invention, there is provided apparatus for securing afirst object to a second object, the apparatus comprising:

an elongated body having a distal end, a proximal end, and a lumenextending between the distal end and the proximal end, the lumencomprising a first section and a second section, the first section ofthe lumen being disposed distal to the second section of the lumen, andwith the first section of the lumen having a wider diameter than thesecond section of the lumen;

at least one longitudinally-extending slit extending through the sidewall of the elongated body and communicating with the lumen, the atleast one longitudinally-extending slit having a distal end and aproximal end, with the distal end of the at least onelongitudinally-extending slit being spaced from the distal end of theelongated body; and

an elongated element extending through the lumen of the elongated body,the elongated element comprising a proximal end and a distal end andhaving an enlargement at its distal end, the enlargement having adiameter greater than the second section of the lumen.

In another form of the invention, there is provided apparatus forsecuring a first object to a second object, the apparatus comprising:

an elongated body having a distal end, a proximal end, and a lumenextending between the distal end and the proximal end, the lumencomprising a first section and a second section, the first section ofthe lumen being disposed distal to the second section of the lumen, andwith the first section of the lumen having a wider diameter than thesecond section of the lumen; and

a suture extending through the lumen of the elongated body, the suturecomprising a proximal end and a distal end and having a suture knot atits distal end, the suture knot having a diameter greater than thesecond section of the lumen.

In another form of the invention, there is provided apparatus forsecuring a first object to a second object, the apparatus comprising:

an elongated body having a distal end, a proximal end, and a lumenextending between the distal end and the proximal end, the lumencomprising a first section and a second section, the first section ofthe lumen being disposed distal to the second section of the lumen andwith the first section of the lumen having a wider diameter than thesecond section of the lumen;

the side wall of the elongated body having a weakened section thereinadjacent to the second section of the lumen; and

an elongated element extending through the lumen of the elongated body,the elongated element comprising a proximal end and a distal end andhaving an enlargement at its distal end, the enlargement having adiameter greater than the second section of the lumen.

In another form of the invention, there is provided a method forsecuring a first object to a second object, the method comprising:

providing apparatus comprising:

-   -   an elongated body having a distal end, a proximal end, and a        lumen extending between the distal end and the proximal end, the        lumen comprising a first section and a second section, the first        section of the lumen being disposed distal to the second section        of the lumen, and with the first section of the lumen having a        wider diameter than the second section of the lumen;    -   at least one longitudinally-extending slit extending through the        side wall of the elongated body and communicating with the        lumen, the at least one longitudinally-extending slit having a        distal end and a proximal end, with the distal end of the at        least one longitudinally-extending slit being spaced from the        distal end of the elongated body; and    -   an elongated element extending through the lumen of the        elongated body, the elongated element comprising a proximal end        and a distal end and having an enlargement at its distal end,        the enlargement having a diameter greater than the second        section of the lumen;

inserting the elongated body into the second object;

moving the enlargement proximally so as to expand the elongated body;and

securing the first object to the second object with the elongatedelement.

In another form of the invention, there is provided a method forsecuring a first object to a second object, the method comprising:

providing apparatus comprising:

-   -   an elongated body having a distal end, a proximal end, and a        lumen extending between the distal end and the proximal end, the        lumen comprising a first section and a second section, the first        section of the lumen being disposed distal to the second section        of the lumen, and with the first section of the lumen having a        wider diameter than the second section of the lumen; and    -   a suture extending through the lumen of the elongated body, the        suture comprising a proximal end and a distal end and having a        suture knot at its distal end, the suture knot having a diameter        greater than the second section of the lumen;

inserting the elongated body into the second object;

moving the suture knot proximally so as to expand the elongated body;and

securing the first object to the second object with the suture.

In another form of the invention, there is provided a method forsecuring a first object to a second object, the method comprising:

providing apparatus comprising:

-   -   an elongated body having a distal end, a proximal end, and a        lumen extending between the distal end and the proximal end, the        lumen comprising a first section and a second section, the first        section of the lumen being disposed distal to the second section        of the lumen, and with the first section of the lumen having a        wider diameter than the second section of the lumen;    -   the side wall of the elongated body having a weakened section        therein adjacent to the second section of the lumen; and    -   an elongated element extending through the lumen of the        elongated body, the elongated element comprising a proximal end        and a distal end and having an enlargement at its distal end,        the enlargement having a diameter greater than the second        section of the lumen;

inserting the elongated body into the second object;

moving the enlargement proximally so as to expand the elongated body;and

securing the first object to the second object with the elongatedelement.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other objects and features of the present invention will bemore fully disclosed or rendered obvious by the following detaileddescription of the preferred embodiments of the invention, which is tobe considered together with the accompanying drawings wherein likenumbers refer to like parts, and further wherein:

FIGS. 1A-1D are schematic views showing various aspects of hip motion;

FIG. 2 is a schematic view showing bone structures in the region of thehip joint;

FIG. 3 is a schematic anterior view of the femur;

FIG. 4 is a schematic posterior view of the top end of the femur;

FIG. 5 is a schematic view of the pelvis;

FIGS. 6-12 are schematic views showing bone and soft tissue structuresin the region of the hip joint;

FIG. 13 is a schematic view showing cam-type femoroacetabularimpingement (i.e., cam-type FAI);

FIG. 14 is a schematic view showing pincer-type femoroacetabularimpingement (i.e., pincer-type FAI);

FIG. 15 is a schematic view showing a labral tear;

FIG. 16 is a schematic view showing a normal labrum which has its basesecurely attached to the acetabulum;

FIG. 17 is a schematic view showing a portion of the labrum detachedfrom the acetabulum;

FIG. 18 is a schematic view showing a bone anchor being used tore-attach the labrum to the acetabulum;

FIGS. 19-27 are schematic views showing a novel suture anchor system foruse in arthroscopically re-attaching a detached labrum to theacetabulum;

FIGS. 28 and 28A are schematic views showing the suture anchor system ofFIGS. 19-27 being used to re-attach the labrum to the acetabulum;

FIGS. 29-31 are schematic views showing an alternative form of thesuture anchor system of the present invention;

FIG. 32 is a schematic view showing another alternative form of thesuture anchor system of the present invention;

FIGS. 33-38 are schematic views showing alternative arrangements forcoupling the anchor of the suture anchor system of FIGS. 19-27 to theinserter of the suture anchor system of FIGS. 19-27;

FIGS. 39-41 are schematic views showing still another alternative formof the suture anchor system of the present invention;

FIG. 42 is a schematic view showing yet another alternative form of thesuture anchor system of the present invention;

FIGS. 43-45 are schematic views showing another alternative form of thesuture anchor system of the present invention;

FIGS. 46-48 are schematic views showing still another alternative formof the suture anchor system of the present invention;

FIGS. 49-50 are schematic views showing yet another alternative form ofthe suture anchor system of the present invention;

FIG. 51 is a schematic view showing another alternative form of thesuture anchor system of the present invention; and

FIGS. 52-54 are schematic views showing still another alternative formof the suture anchor system of the present invention; and

FIGS. 55-60 are schematic views showing yet another alternative form ofthe present invention.

DETAILED DESCRIPTION OF THE INVENTION The Novel Suture Anchor System ofthe Present Invention in General

The present invention provides a novel method and apparatus forarthroscopically re-attaching the labrum to the acetabulum. Among otherthings, the present invention comprises the provision and use of a novelsuture anchor system.

More particularly, and looking now at FIG. 19, there is shown a novelsuture anchor system 5 for use in arthroscopically re-attaching adetached labrum to the acetabulum. Suture anchor system 5 generallycomprises an anchor 10, a suture 15 secured to anchor 10, and aninserter 20 for delivering anchor 10 into the acetabulum, whereby suture15 may be used to secure a detached labrum to the acetabular rim as willhereinafter be discussed in further detail. Suture anchor system 5preferably also comprises a hollow guide 25 for delivering componentsfrom outside of the body to the acetabulum, and a punch (or drill) 30which may be used to prepare a seat for anchor 10 in the acetabulum.

Looking next at FIGS. 19-23, anchor 10 comprises a generally cylindricalbody 35 having a distal end 40, a proximal end 45, and a lumen 50extending between distal end 40 and proximal end 45. In one preferredform of the present invention, lumen 50 comprises a distal end reservoir55, a short intermediate portion 60, and an elongated proximal portion65. As seen in FIG. 23, distal end reservoir 55 has a diameter which isgreater than the diameter of short intermediate portion 60, and shortintermediate portion 60 has a diameter which is greater than thediameter of elongated proximal portion 65. And in one preferred form ofthe present invention, the outer surface of generally cylindrical body35 comprises a plurality of ribs 70 spaced along the length of generallycylindrical body 35, so as to enhance the “holding power” of anchor 10in bone. In one particularly preferred form of the present invention,ribs 70 sub-divide the length of generally cylindrical body 35 into aplurality of segments, with each segment having a generallyfrusto-conical configuration (FIGS. 21 and 22).

Near (but spaced from) the distal end 40 of generally cylindrical body35, there is provided a longitudinally-extending slit 75 which extendscompletely through one side wall (but not the other) of generallycylindrical body 35. Thus, longitudinally-extending slit 75 communicateswith lumen 50 of anchor 10. The distal end of longitudinally-extendingslit 75 terminates in a distal relief hole 80, and the proximal end oflongitudinally-extending slit 75 terminates in a proximal relief hole85. It will be appreciated that distal relief hole 80 is spaced fromdistal end 40 of generally cylindrical body 35, so that a solid distalring 90 is located at the distal end of generally cylindrical body 35,whereby to provide the distal end of generally cylindrical body 35 witha degree of structural integrity.

Looking now at FIGS. 20 and 24-26, suture 15 generally comprises adistal loop 95 terminating in an enlargement 100 at its distal end andconnected to a proximal open loop 105 at its proximal end. Moreparticularly, distal loop 95 extends through short intermediate portion60 and elongated proximal portion 65 of lumen 50. Enlargement 100 maycomprise a solid member (e.g., cylindrical, conical, etc.) attached tothe distal end of distal loop 95, or it may comprise a suture knotformed by knotting off the distal ends of distal loop 95 of suture 15,etc. Where enlargement 100 comprises a suture knot, this suture knot mayor may not be hardened, shaped or stabilized with cement, heat, etc. Forpurposes of illustration, enlargement 100 is shown in the drawingsschematically, i.e., as a generally cylindrical structure, but it shouldbe appreciated that this is being done solely for clarity ofillustration, and enlargement 100 may assume any other shapes and/orconfigurations (including that of a suture knot) consistent with thepresent invention. Enlargement 100 is sized so that it is small enoughto be seated in distal end reservoir 55 of generally cylindrical body 35(see, for example, FIGS. 24 and 25), but large enough so that it may notenter short intermediate portion 60 of generally cylindrical body 35without causing radial expansion of generally cylindrical body 35 (see,for example, FIG. 26). Proximal open loop 105 extends back through theinterior of inserter 20 (FIGS. 19 and 20) and provides a pair of freesuture ends emanating from the proximal end of inserter 20 (FIG. 19), aswill hereinafter be discussed.

Looking now at FIGS. 19 and 20, inserter 20 generally comprises a hollowpush tube 110 having a lumen 115 extending therethrough. Inserter 20terminates at its distal end in a drive surface 120 for engaging theproximal end 45 of anchor 10, and terminates at its proximal end in ahandle 125. Handle 125 may include features to secure the free ends ofsuture 15, e.g., one or more suture cleats, suture slots, suture clamps,etc. Where such features are provided, and where appropriate, handle 125may also include one or more release mechanisms to release the free endsof suture 15. Handle 125 may also have one or more mechanisms to applytension to the secured free ends of suture 15. Suture 15 (i.e., proximalopen loop 105 of suture 15) extends through lumen 115 of hollow pushtube 110. By maintaining a slight proximally-directed tension on theproximal end of suture 15 (e.g., by maintaining a slightproximally-directed tension on the free suture ends of proximal openloop 105), anchor 10 can be held against the drive surface 120 of hollowpush tube 110, thereby providing a degree of control for maneuvering theanchor.

Preferably anchor 10, suture 15 and inserter 20 are pre-assembled into asingle unit, with suture 15 extending back through lumen 115 of inserter20 with a slight proximal tension so as to hold anchor 10 on the distalend of inserter 20.

Suture anchor system 5 preferably also comprises a hollow guide 25 forguiding components from outside of the body to the acetabulum. Moreparticularly, hollow guide 25 generally comprises a lumen 130 forslidably receiving anchor 10 and inserter 20 therein, as willhereinafter be discussed. The internal diameter of hollow guide 25 ispreferably approximately equal to the largest external feature of anchor10 (e.g., one or more of the barbs 70), so that anchor 10 can make aclose sliding fit within the interior of hollow guide 25. Alternatively,the internal diameter of hollow guide 25 may be slightly smaller orlarger than the largest external feature of anchor 10 if desired. Wheresuture anchor system 5 also comprises a punch (or drill) 30, lumen 130of hollow guide 25 is preferably sized to slidably receive punch (ordrill) 30, as will hereinafter be discussed. The distal end of hollowguide 25 preferably includes a sharp tip/edge for penetrating the labrumand engaging the acetabulum, as will hereinafter be discussed.

If desired, and looking now at FIGS. 19 and 27, suture anchor system 5may also comprise a punch (or drill) 30 having a sharp distal end 135and a proximal end 140 having a handle 145 mounted thereto. Whereelement 30 is a drill, handle 145 could comprise a mount for the drillso as to facilitate turning the drill with a powered driver, etc. Again,the sharp distal end 135 of punch (or drill) 30 is adapted to penetratethe acetabulum, as will hereinafter be discussed.

Method for Arthroscopically Re-Attaching the Labrum to the AcetabulumUsing the Novel Suture Anchor System of the Present Invention

Suture anchor system 5 is preferably used as follows to secure adetached labrum to the acetabulum.

First, the sharp distal end 136 of hollow guide 25 is passed through thelabrum and positioned against the acetabulum at the location whereanchor 10 is to be deployed. Preferably the sharp distal end of hollowguide 25 penetrates through the labrum and a short distance into theacetabulum so as to stabilize the hollow guide vis-à-vis the acetabulum.A stylet (e.g., an obturator) may be used to fill the hollow guide 25during such insertion and thus prevent tissue coring of the labrumduring insertion. The distal portion of the punch (or drill) 30 may alsobe used to fill the hollow tip of the hollow guide 25 during suchinsertion.

Next, if desired, punch (or drill) 30 may be used to prepare a seat inthe acetabulum to receive anchor 10. More particularly, if punch (ordrill) 30 is used, the sharp distal end 135 of punch (or drill) 30 ispassed through hollow guide 25 (thereby also passing through the labrum)and advanced into the acetabulum so as to form an opening (i.e., a seat)in the bone to receive anchor 10. Then, while hollow guide 25 remainsstationary, punch (or drill) 30 is removed from hollow guide 25.

Next, inserter 20, carrying anchor 10 thereon, is passed through hollowguide 25 (thereby also passing through the labrum) and into the seatformed in the acetabulum. As anchor 10 is advanced into the bone, thebody of anchor 10 (e.g., ribs 70) makes an interference fit with thesurrounding bone, whereby to initially bind the anchor to the bone. Atthe same time, the solid distal ring 90 located at the distal end of theanchor provides the structural integrity needed to keep the anchorintact while it penetrates into the bone. When anchor 10 has beenadvanced an appropriate distance into the acetabulum, the proximal endof suture 15 (i.e., proximal open loop 105) is pulled proximally whilethe distal end of inserter 20 is held in position, thereby causingenlargement 100 to move proximally relative to the generally cylindricalbody 35, forcing the distal end of generally cylindrical body 35 tosplit and expand, in the manner shown in FIG. 26, whereby to furtherbind anchor 10, and hence suture 15, to the bone. In one preferred formof the present invention, expansion of generally cylindrical body 35occurs along some or all of the circumference of the generallycylindrical body, and there may be variations in the amount of expansionabout the circumference of the generally cylindrical body, e.g., withthe construction shown in FIG. 26, there may be greater expansion in adirection perpendicular to the direction of longitudinally-extendingslits 75 (for example, in the direction of the arrows shown in FIG. 26).It will be appreciated that the location and magnitude of expansion ofgenerally cylindrical body 35 can be controlled by the number andlocation of longitudinally-extending slits 75, the configuration ofenlargement 100, the configuration of generally cylindrical body 35(e.g., its lumen 50 and the associated side wall of the cylindrical body35 adjacent the lumen), etc. In one preferred form of the presentinvention, expansion of generally cylindrical body 35 occurs at the zonewhere distal end reservoir 55 meets short intermediate portion 60, withexpansion occurring as enlargement 100 moves out of the comparativelylarger diameter distal end reservoir 55 and into the comparativelysmaller diameter intermediate portion 60.

Significantly, in view of the modest holding power required to securethe labrum in place, anchor 10 can have a very small size, much smallerthan a typical bone anchor of the sort used to hold a ligament in place.By way of example but not limitation, anchor 10 may have a length of0.325 inches, an outer diameter (unexpanded) of 0.063 inches, and anouter diameter (expanded) of 0.080 inches. This small size enables aminimal puncture to be made in the labrum (and hence a minimal hole tobe made in the labrum), thus reducing potential damage to the labraltissue and enabling a more accurate puncture location through thelabrum. The small size of anchor 10 also allows the anchor to be placedcloser to, or directly into, the rim of the acetabular cup, without fearof the anchor penetrating into the articulating surfaces of the joint.See, for example, FIG. 28, which shows anchor 10 placed close to the rimof the acetabular cup, and FIG. 28A, which shows anchor 10 placeddirectly into the rim of the acetabular cup. This significantly reduces,or entirely eliminates, the labrum eversion problems discussed above.Furthermore, the small size of the anchor significantly reduces traumato the tissue of the patient.

Once anchor 10 has been set in the acetabulum, guide 25 is removed fromthe surgical site, leaving anchor 10 deployed in the acetabulum andsuture 15 extending out through the labrum.

This process may then be repeated as desired so as to deploy additionalanchors through the labrum and into the acetabulum, with each anchorhaving a pair of associated free suture ends extending out through thelabrum.

Finally, the labrum may be secured to the acetabular cup by tying thelabrum down to the acetabulum using the free suture ends emanating fromthe one or more anchors.

Some Alternative Constructions for the Novel Suture Anchor System of thePresent Invention

If desired, and looking now at FIGS. 29-31, a deployment cylinder 150may be disposed on distal loop 95 of suture 15 just proximal toenlargement 100. Deployment cylinder 150 can be advantageous whereenlargement 100 comprises a suture knot, since the deployment cylindercan ensure the uniform application of a radial expansion force to thewall of the anchor body even where the suture knot has a non-uniformconfiguration. Deployment cylinder 150 may have a beveled proximal end155 to facilitate expansion of anchor 10 when suture 15 is pulledproximally. FIG. 29 depicts anchor 10 in an unexpanded state, whileFIGS. 30-31 depict the anchor 10 in an expanded state.

Furthermore, one or more of the ribs 70 may utilize a differentconstruction than that shown in FIGS. 21-23. More particularly, in FIGS.21-23, each of the ribs 70 comprises a proximal portion which comprisesa cylindrical surface 160. Such a cylindrical surface provides increasedsurface area contact for engaging the adjacent bone when anchor 10 isdisposed in the acetabulum. However, if desired, one or more of the ribs70 may terminate in a sharp proximal rim 165 (FIGS. 29-31) for bitinginto adjacent bone when suture 15 is pulled proximally.

Or one or more of the ribs 70 may be slotted as shown in FIG. 32 so asto provide a rib with increased flexibility. Such a construction can beuseful since it allows the slotted rib 70 to be radially compressed soas to fit within inserter 20 and then radially expanded, in aspring-like manner, when deployed in the acetabulum.

If desired, alternative arrangements can be provided for coupling anchor10 to the distal end of inserter 20. More particularly, in FIGS. 33 and34, a male-female connection is used to couple anchor 10 to inserter 20,with anchor 10 having a male projection 170 and inserter 20 having acorresponding female recess 175. In FIGS. 35 and 36, inserter 20includes the male projection 170 and anchor 10 has the correspondingfemale recess 175. In FIGS. 37 and 38, inserter 20 has a convex surface180 and anchor 10 has a corresponding concave surface 185. Still otherconstructions of this type will be apparent to those skilled in the artin view of the present disclosure.

Looking next at FIGS. 39-41, in another form of present invention,suture 15 is intended to exit anchor 10 at proximal relief hole 85 andextend along the exterior of the generally cylindrical body 35. Ifdesired, slots 190 may be provided in ribs 70 so as to accommodatesuture 15 therein.

In another form of the present invention, and looking now at FIG. 42,suture 15 can be replaced by a solid shaft 195. More particularly, solidshaft 195 extends through lumen 50 of anchor 10 and lumen 115 ofinserter 20, and has enlargement 100 formed on its distal end. Proximalmovement of solid shaft 195 causes enlargement 100 to expand the distalend of anchor 10 so as to cause anchor 10 to grip adjacent bone.

If desired, one or both of distal relief hole 80 and proximal reliefhole 85 may be omitted, with longitudinally-extending slit 75terminating in a blind surface at one or both ends.

Furthermore, if desired more than one longitudinally-extending slit 75may be provided in anchor 10, e.g., two diametrically-opposedlongitudinally-extending slits 75 may be provided. Additionally, ifdesired, longitudinally-extending slit 75 may extend all the way to thedistal end of the anchor body, rather than stopping short of the distalend of the anchor body. See, for example, FIGS. 43 and 44, which showtwo diametrically-opposed, longitudinally-extending slits 75, whereinthe slits extend all the way to the distal end of anchor 10, and withthe two figures showing examplary rib configurations. See also FIG. 45,which shows an anchor 10 having a single longitudinally-extending slit75, wherein the slit extends all the way to the distal end of theanchor.

If desired, and looking now at FIGS. 46-48, lumen 50 may extend along alongitudinal axis 200 which is eccentric to the longitudinal axis 205 ofgenerally cylindrical body 35. Such an eccentric construction canprovide a thinner side wall on one side of the anchor and a thicker sidewall on another side of the anchor, so as to create preferential bodyexpansion.

Or anchor 10 may be provided with an angled through-hole to createvarying wall thicknesses and non-symmetric effects as shown in FIGS. 49and 50.

If desired, and looking now at FIG. 51, anchor 10 can be constructed sothat longitudinally-extending slit 75 is omitted entirely. In this formof the invention, anchor 10 is preferably formed with one or morethin-walled sections 210 (FIGS. 52-54) which fracture when enlargement100 is forced proximally.

Alternatively, in another form of the invention, anchor 10 isconstructed so that its generally cylindrical body 35 expands radiallywhen enlargement 100 moves proximally, but the distal end of the anchordoes not split open. See FIGS. 55-58. Again, the direction and extent ofthe expansion of cylindrical body 35 may be controlled by the number andlocation of the longitudinally-extending slits 75, the configuration ofenlargement 100, the configuration of generally cylindrical body 35(e.g., its lumen 50 and the associated side wall of the cylindrical body35 adjacent the lumen), etc.

Additional Construction Details

Anchor 10 can be made out of any material consistent with the presentinvention, e.g., anchor 10 can be made out of a biocompatible plastic(such as PEEK), an absorbable polymer (such as poly-L-lactic acid,PLLA), bio-active materials such as hydrogels, or metal (such asstainless steel or titanium).

Suture 15 can be made out of any material consistent with the presentinvention, e.g., common surgical suture materials. One such material iswoven polymer such as PE or UHMWPE. Another material is a co-polymermaterial such as UHMWPE/polyester. Yet another material is an absorbablepolymer such as polyglycolic acid, polylactic acid, polydioxanone, orcaprolactone. Proximal loop 105 is preferably a #1 suture size;alternatively, it is a #2 suture size, a #0 suture size, or a #2-0suture size. Distal loop 95 is preferably a #2-0 suture size;alternatively, it is a #2 suture size, a #1 suture size, or a #0 suturesize.

As noted above, enlargement 100 may comprise a solid member attached tothe distal end of distal loop 95, or it may comprise a suture knotformed by knotting off the distal ends of distal loop 95 of suture 15.In this latter construction, enlargement 100 can be formed out of asingle knot or multiple knots. It can be an overhand knot or other knotsuch as a “Figure 8” knot. Suture 15 can also be heat formed so as tocreate the enlargement 100. This will create a more rigid feature thatbetter enables movement of enlargement 100 from its distal position toits more proximal position. Such heat forming could also be done on aknot or to seal the suture ends distal to the knot.

Alternative Construction and Method of Use

In one form of the present invention, anchor 10 of suture anchor system5 may be delivered trans-labrally, i.e., through the labrum and into theacetabular bone, e.g., such as was described above.

In an alternative embodiment of the present invention, anchor 10 may beplaced directly into the acetabular bone, without passing through thelabrum first, and then suture 15 may be passed through the labrum. Inthis form of the invention, the components of suture anchor system 5 mayremain the same. Alternatively, in this form of the invention, thedistal end of hollow guide 25 need not have a sharp tip/edge 136 forpenetrating the labrum as described above, and may instead haveengagement features for engaging the acetabular bone. One such featuremay be a tooth or a plurality of teeth. In this form of the invention,the distal end of the hollow guide may also include a window forconfirming that the anchor is properly placed into the bone.

Curved or Angled Configuration and Method of Use

Suture anchor system 5 may also comprise a curved or angledconfiguration. More particularly, hollow guide 25 may comprise a curveor angle at its distal end. In this form of the invention, the punch (ordrill) 30, inserter 20 and anchor 10 are adapted to pass through thecurved or angled hollow guide 25 so as to permit a curved or angleddelivery of anchor 10.

Use of the Novel Suture Anchor System for Other Tissue Re-Attachment

It should be appreciated that suture anchor system 5 may also be usedfor re-attaching other soft tissue of the hip joint, or for re-attachingtissue of other joints, or for re-attaching tissue elsewhere in thebody. In this respect it should be appreciated that suture anchor system5 may be used to attach soft tissue to bone or soft tissue to other softtissue, or for attaching objects (e.g., prostheses) to bone othertissue.

Modifications of the Preferred Embodiments

It should be understood that many additional changes in the details,materials, steps and arrangements of parts, which have been hereindescribed and illustrated in order to explain the nature of the presentinvention, may be made by those skilled in the art while still remainingwithin the principles and scope of the invention.

What is claimed is:
 1. Apparatus for securing a first object to a secondobject, the apparatus comprising: an elongated body having a distal end,a proximal end, and a lumen opening on the proximal end and extendingtoward the distal end, the lumen comprising a first portion and a secondportion, the first portion of the lumen being disposed distal to thesecond portion of the lumen, and with the first portion of the lumenhaving a wider diameter than the second portion of the lumen; at leastone slit extending through the side wall of the elongated body andcommunicating with the lumen, the at least one slit having a distal endand a proximal end, with the distal end of the at least one slit beingspaced from the distal end of the elongated body and with the proximalend of the at least one slit being spaced from the proximal end of theelongated body, wherein the at least one slit is not connected to anadjacent slit by a connecting slit; and an elongated element extendingthrough the lumen of the elongated body, the elongated elementcomprising a proximal end and a distal end and having an enlargement atits distal end, the enlargement having a diameter greater than thesecond portion of the lumen.
 2. Apparatus according to claim 1 whereinat least one of the distal end of the at least one slit and the proximalend of the at least one slit terminates in a relief hole.
 3. Apparatusaccording to claim 1 wherein there are two slits, and further whereinthe two slits are on opposite sides of the elongated body.
 4. Apparatusaccording to claim 1 wherein the elongated element comprises a suture.5. Apparatus according to claim 4 wherein the suture comprises (i) adistal loop connected to the enlargement, and (ii) a proximal loopconnected to the distal loop.
 6. Apparatus according to claim 5 whereinthe distal loop comprises suture of a first maximum width and theproximal loop comprises suture of a second maximum width.
 7. Apparatusaccording to claim 6 wherein the second maximum width is larger than thefirst maximum width.
 8. Apparatus according to claim 5 wherein thedistal loop extends out of the lumen of the elongated body, with thedistal loop and the elongated body together forming an eyelet. 9.Apparatus according to claim 4 wherein the enlargement comprises asuture knot.
 10. Apparatus according to claim 4 wherein the enlargementcomprises a solid member and a suture knot, the solid member beingdisposed proximal to the suture knot.
 11. Apparatus according to claim 1wherein the lumen further comprises a third portion disposed proximal tothe second portion of the lumen, the third portion of the lumen having adiameter smaller than the second portion of the lumen.
 12. Apparatusaccording to claim 1 wherein the enlargement is configured to expand theelongated body, and further wherein expansion of the elongated body doesnot cause the distal end of the elongated body to split open. 13.Apparatus according to claim 1 wherein the enlargement is configured toexpand the elongated body, and further wherein expansion of theelongated body does not cause the proximal end of the elongated body tosplit open.
 14. Apparatus according to claim 1 wherein the enlargementis initially at least partially disposed in the first portion of thelumen.
 15. Apparatus according to claim 1 wherein the enlargementexpands the elongated body when the enlargement is pulled proximallyinto the second portion of the lumen.
 16. Apparatus according to claim 1wherein the enlargement comprises a solid member.
 17. Apparatusaccording to claim 1 wherein the proximal end of the elongated elementextends through the second portion of the lumen of the elongated bodyand has a maximum width, and further wherein a second elongated elementis connected to the elongated element external to the elongated body,the second elongated element having a width, wherein the width of thesecond elongated element is larger than the maximum width of theproximal end of the elongated element.
 18. Apparatus according to claim1 wherein the distal end of the at least one slit is adjacent to thefirst portion of the lumen of the elongated body.
 19. Apparatusaccording to claim 18 wherein the proximal end of the at least one slitis proximal to the first portion of the lumen of the elongated body. 20.Apparatus according to claim 1 further comprising an inserter, whereinthe elongated body is held to the inserter by applyingproximally-directed tension to the elongated element.
 21. A method forsecuring a first object to a second object, the method comprising:providing apparatus comprising: an elongated body having a distal end, aproximal end, and a lumen extending between the distal end and theproximal end, the lumen comprising a first portion and a second portion,the first portion of the lumen being disposed distal to the secondportion of the lumen, and with the first portion of the lumen having awider diameter than the second portion of the lumen; at least one slitextending through the side wall of the elongated body and communicatingwith the lumen, the at least one slit having a distal end and a proximalend, with the distal end of the at least one slit being spaced from thedistal end of the elongated body and with the proximal end of the atleast one slit being spaced from the proximal end of the elongated body,wherein the at least one slit is not connected to an adjacent slit by aconnecting slit; and an elongated element extending through the lumen ofthe elongated body, the elongated element comprising a proximal end anda distal end and having an enlargement at its distal end, theenlargement having a diameter greater than the second portion of thelumen; inserting the elongated body into the second object; moving theenlargement proximally so as to expand the elongated body; and securingthe first object to the second object with the elongated element. 22.Apparatus for securing a first object to a second object, the apparatuscomprising: an elongated body having a distal end, a proximal end, and alumen opening on the proximal end and extending toward the distal end,the lumen comprising a first portion and a second portion, the firstportion of the lumen being disposed distal to the second portion of thelumen, and with the first portion of the lumen having a wider diameterthan the second portion of the lumen; at least onelongitudinally-extending slit extending through the side wall of theelongated body and communicating with the lumen, the at least onelongitudinally-extending slit having a distal end and a proximal end,with the distal end of the at least one longitudinally-extending slitbeing spaced from the distal end of the elongated body and with theproximal end of the at least one longitudinally-extending slit beingspaced from the proximal end of the elongated body; and an elongatedelement extending through the lumen of the elongated body, the elongatedelement comprising a proximal end and a distal end and having anenlargement at its distal end, the enlargement having a diameter greaterthan the second portion of the lumen; wherein the elongated elementcomprises a suture; wherein the suture comprises (i) a distal loopconnected to the enlargement, and (ii) a proximal loop connected to thedistal loop; wherein the distal loop comprises suture of a firstdiameter and the proximal loop comprises suture of a second diameter.23. Apparatus according to claim 22 wherein the second diameter islarger than the first diameter.
 24. Apparatus according to claim 23wherein the distal loop is formed out of #2-0 suture and the proximalloop is formed out of #1 suture.
 25. Apparatus for securing a firstobject to a second object, the apparatus comprising: an elongated bodyhaving a distal end, a proximal end, and a lumen opening on the proximalend and extending toward the distal end, the lumen comprising a firstportion and a second portion, the first portion of the lumen beingdisposed distal to the second portion of the lumen, and with the firstportion of the lumen having a wider diameter than the second portion ofthe lumen; at least two slits extending through the side wall of theelongated body and communicating with the lumen, each of the at leasttwo slits having a distal end and a proximal end, with each of thedistal ends of the at least two slits being spaced from the distal endof the elongated body, with each of the proximal ends of the at leasttwo slits being spaced from the proximal end of the elongated body, andthe at least two slits being spaced from one another with a portion ofthe side wall of the elongated body extending therebetween; and anelongated element extending through the lumen of the elongated body, theelongated element comprising a proximal end and a distal end and havingan enlargement at its distal end, the enlargement having a diametergreater than the second portion of the lumen; wherein movement of theenlargement into the second portion of the lumen causes the elongatedbody to expand, and further wherein the portion of the side wall of theelongated body extending between the at least two slits remainsconnected to the elongated body distal to the at least two slits andproximal to the at least two slits after expansion of the elongatedbody.
 26. Apparatus according to claim 25 wherein at least one of thedistal ends of the at least two slits and the proximal ends of the atleast two slits terminates in a relief hole.
 27. Apparatus according toclaim 25 wherein the at least two slits are on opposite sides of theelongated body.
 28. Apparatus according to claim 25 wherein theelongated element comprises a suture.
 29. Apparatus according to claim28 wherein the suture comprises (i) a distal loop connected to theenlargement, and (ii) a proximal loop connected to the distal loop. 30.Apparatus according to claim 29 wherein the distal loop comprises sutureof a first maximum width and the proximal loop comprises suture of asecond maximum width.
 31. Apparatus according to claim 30 wherein thesecond maximum width is larger than the first maximum width. 32.Apparatus according to claim 29 wherein the distal loop extends out ofthe lumen of the elongated body, with the distal loop and the elongatedbody together forming an eyelet.
 33. Apparatus according to claim 28wherein the enlargement comprises a suture knot.
 34. Apparatus accordingto claim 28 wherein the enlargement comprises a solid member and asuture knot, the solid member being disposed proximal to the sutureknot.
 35. Apparatus according to claim 25 wherein the lumen furthercomprises a third portion disposed proximal to the second portion of thelumen, the third portion of the lumen having a diameter smaller than thesecond portion of the lumen.
 36. Apparatus according to claim 25 whereinthe enlargement is initially at least partially disposed in the firstportion of the lumen.
 37. Apparatus according to claim 25 whereinexpansion of the elongated body does not cause the distal end of theelongated body to split open.
 38. Apparatus according to claim 25wherein expansion of the elongated body does not cause the proximal endof the elongated body to split open.
 39. Apparatus according to claim 25wherein the enlargement comprises a solid member.
 40. Apparatusaccording to claim 25 wherein the proximal end of the elongated elementextends through the second portion of the lumen of the elongated bodyand has a maximum width, and further wherein a second elongated elementis connected to the elongated element external to the elongated body,the second elongated element having a width, wherein the width of thesecond elongated element is larger than the maximum width of theproximal end of the elongated element.
 41. Apparatus according to claim25 wherein the distal ends of the at least two slits are adjacent to thefirst portion of the lumen of the elongated body.
 42. Apparatusaccording to claim 41 wherein the proximal ends of the at least twoslits are proximal to the first portion of the lumen of the elongatedbody.
 43. Apparatus according to claim 25 further comprising aninserter, wherein the elongated body is held to the inserter by applyingproximally-directed tension to the elongated element.
 44. Apparatus forsecuring a first object to a second object, the apparatus comprising: anelongated body having a distal end, a proximal end, and a lumen openingon the proximal end and extending toward the distal end, the lumencomprising a first portion and a second portion, the first portion ofthe lumen being disposed distal to the second portion of the lumen, andwith the first portion of the lumen having a wider diameter than thesecond portion of the lumen; at least one slit extending through theside wall of the elongated body and communicating with the lumen,wherein the at least one slit has a distal end and a proximal end, withthe distal end of the at least one slit being spaced from the distal endof the elongated body and with the proximal end of the at least one slitbeing spaced from the proximal end of the elongated body; and anelongated element extending through the lumen of the elongated body, theelongated element comprising a proximal end and a distal end and havingan enlargement at its distal end, the enlargement having a diametergreater than the second portion of the lumen; wherein movement of theenlargement into the second portion of the lumen causes the elongatedbody to expand, and further wherein during expansion of the elongatedbody, the side wall of the elongated body expands radially on both sidesof the at least one slit.
 45. Apparatus according to claim 44 wherein atleast one of the distal end of the at least one slit and the proximalend of the at least one slit terminates in a relief hole.
 46. Apparatusaccording to claim 44 wherein there are two slits, and further whereinthe two slits are on opposite sides of the elongated body.
 47. Apparatusaccording to claim 44 wherein the elongated element comprises a suture.48. Apparatus according to claim 47 wherein the suture comprises (i) adistal loop connected to the enlargement, and (ii) a proximal loopconnected to the distal loop.
 49. Apparatus according to claim 48wherein the distal loop comprises suture of a first maximum width andthe proximal loop comprises suture of a second maximum width. 50.Apparatus according to claim 49 wherein the second maximum width islarger than the first maximum width.
 51. Apparatus according to claim 48wherein the distal loop extends out of the lumen of the elongated body,with the distal loop and the elongated body together forming an eyelet.52. Apparatus according to claim 47 wherein the enlargement comprises asuture knot.
 53. Apparatus according to claim 47 wherein the enlargementcomprises a solid member and a suture knot, the solid member beingdisposed proximal to the suture knot.
 54. Apparatus according to claim44 wherein the lumen further comprises a third portion disposed proximalto the second portion of the lumen, the third portion of the lumenhaving a diameter smaller than the second portion of the lumen. 55.Apparatus according to claim 44 wherein the enlargement is initially atleast partially disposed in the first portion of the lumen. 56.Apparatus according to claim 44 wherein expansion of the elongated bodydoes not cause the distal end of the elongated body to split open. 57.Apparatus according to claim 44 wherein expansion of the elongated bodydoes not cause the proximal end of the elongated body to split open. 58.Apparatus according to claim 44 wherein the enlargement comprises asolid member.
 59. Apparatus according to claim 44 wherein the proximalend of the elongated element extends through the second portion of thelumen of the elongated body and has a maximum width, and further whereina second elongated element is connected to the elongated elementexternal to the elongated body, the second elongated element having awidth, wherein the width of the second elongated element is larger thanthe maximum width of the proximal end of the elongated element. 60.Apparatus according to claim 44 wherein the distal end of the at leastone slit is adjacent to the first portion of the lumen of the elongatedbody.
 61. Apparatus according to claim 60 wherein the proximal end ofthe at least one slit is proximal to the first portion of the lumen ofthe elongated body.
 62. Apparatus according to claim 44 furthercomprising an inserter, wherein the elongated body is held to theinserter by applying proximally-directed tension to the elongatedelement.
 63. A method for securing a first object to a second object,the method comprising: providing apparatus comprising: an elongated bodyhaving a distal end, a proximal end, and a lumen opening on the proximalend and extending toward the distal end, the lumen comprising a firstportion and a second portion, the first portion of the lumen beingdisposed distal to the second portion of the lumen, and with the firstportion of the lumen having a wider diameter than the second portion ofthe lumen; at least two slits extending through the side wall of theelongated body and communicating with the lumen, each of the at leasttwo slits having a distal end and a proximal end, with each of thedistal ends of the at least two slits being spaced from the distal endof the elongated body, with each of the proximal ends of the at leasttwo slits being spaced from the proximal end of the elongated body, andthe at least two slits being spaced from one another with a portion ofthe side wall of the elongated body extending therebetween; and anelongated element extending through the lumen of the elongated body, theelongated element comprising a proximal end and a distal end and havingan enlargement at its distal end, the enlargement having a diametergreater than the second portion of the lumen; inserting the elongatedbody into the second object; moving the enlargement proximally so as toexpand the elongated body, wherein movement of the enlargement into thesecond portion of the lumen causes the elongated body to expand, andfurther wherein the portion of the side wall of the elongated bodyextending between the at least two slits remains connected to theelongated body distal to the at least two slits and proximal to the atleast two slits after expansion of the elongated body; and securing thefirst object to the second object with the elongated element.
 64. Amethod for securing a first object to a second object, the methodcomprising: providing apparatus comprising: an elongated body having adistal end, a proximal end, and a lumen opening on the proximal end andextending toward the distal end, the lumen comprising a first portionand a second portion, the first portion of the lumen being disposeddistal to the second portion of the lumen, and with the first portion ofthe lumen having a wider diameter than the second portion of the lumen;at least one slit extending through the side wall of the elongated bodyand communicating with the lumen, wherein the at least one slit has adistal end and a proximal end, with the distal end of the at least oneslit being spaced from the distal end of the elongated body and with theproximal end of the at least one slit being spaced from the proximal endof the elongated body; and an elongated element extending through thelumen of the elongated body, the elongated element comprising a proximalend and a distal end and having an enlargement at its distal end, theenlargement having a diameter greater than the second portion of thelumen; inserting the elongated body into the second object; moving theenlargement proximally so as to expand the elongated body, whereinmovement of the enlargement into the second portion of the lumen causesthe elongated body to expand, and further wherein during expansion ofthe elongated body, the side wall of the elongated body expands radiallyon both sides of the at least one slit; and securing the first object tothe second object with the elongated element.